anemia is the most frequent presenting feature of celiac disease in adults using endomysial antibody (EmA) screening. Endomysial antibody screening of anemia may allow detection of celiac disease at ...an earlier stage of investigation and after a shorter duration of symptoms. The characteristics of celiac patients identified by screening require further study.
a goal of this study was to evaluate the prevalence of celiac disease in adult patients with iron deficiency anemia compared with a nonanemic control population using immunoglobulin A (IgA) EmA screening. We also studied the positive predictive value (PPV) of the EmA assay and correlated the severity of histologic abnormalities in distal duodenal biopsy samples with EmA and tissue transglutaminase (tTG) antibody titer.
four hundred eighty-four patients with microcytic, hypochromic anemia underwent IgA EmA assay. Four hundred ninety-eight nonanemic age- and sex-matched patients from the same source comprised the control group. Patients with positive serology results were invited for endoscopic duodenal biopsies.
one in 44 anemic patients was diagnosed with histologically confirmed celiac disease compared with one in 498 nonanemic patients ( < 0.01). Fifty percent of women were premenopausal, and 25% of patients were older than 65 years. The PPV for EmA assay varied between 73% and 93% for anemic patients and improved at higher antibody titer, with all false-positive results occurring at the lowest titers.
screening for celiac disease using IgA EmA assay is effective in anemic patients, including premenopausal women and patients older than 65 years, and it can be recommended in clinical practice.
Oesophageal adenocarcinoma is the sixth most common cause of cancer death worldwide and Barrett's oesophagus is the biggest risk factor. We aimed to evaluate the efficacy of high-dose esomeprazole ...proton-pump inhibitor (PPI) and aspirin for improving outcomes in patients with Barrett's oesophagus.
The Aspirin and Esomeprazole Chemoprevention in Barrett's metaplasia Trial had a 2 × 2 factorial design and was done at 84 centres in the UK and one in Canada. Patients with Barrett's oesophagus of 1 cm or more were randomised 1:1:1:1 using a computer-generated schedule held in a central trials unit to receive high-dose (40 mg twice-daily) or low-dose (20 mg once-daily) PPI, with or without aspirin (300 mg per day in the UK, 325 mg per day in Canada) for at least 8 years, in an unblinded manner. Reporting pathologists were masked to treatment allocation. The primary composite endpoint was time to all-cause mortality, oesophageal adenocarcinoma, or high-grade dysplasia, which was analysed with accelerated failure time modelling adjusted for minimisation factors (age, Barrett's oesophagus length, intestinal metaplasia) in all patients in the intention-to-treat population. This trial is registered with EudraCT, number 2004-003836-77.
Between March 10, 2005, and March 1, 2009, 2557 patients were recruited. 705 patients were assigned to low-dose PPI and no aspirin, 704 to high-dose PPI and no aspirin, 571 to low-dose PPI and aspirin, and 577 to high-dose PPI and aspirin. Median follow-up and treatment duration was 8·9 years (IQR 8·2–9·8), and we collected 20 095 follow-up years and 99·9% of planned data. 313 primary events occurred. High-dose PPI (139 events in 1270 patients) was superior to low-dose PPI (174 events in 1265 patients; time ratio TR 1·27, 95% CI 1·01–1·58, p=0·038). Aspirin (127 events in 1138 patients) was not significantly better than no aspirin (154 events in 1142 patients; TR 1·24, 0·98–1·57, p=0·068). If patients using non-steroidal anti-inflammatory drugs were censored at the time of first use, aspirin was significantly better than no aspirin (TR 1·29, 1·01–1·66, p=0·043; n=2236). Combining high-dose PPI with aspirin had the strongest effect compared with low-dose PPI without aspirin (TR 1·59, 1·14–2·23, p=0·0068). The numbers needed to treat were 34 for PPI and 43 for aspirin. Only 28 (1%) participants reported study-treatment-related serious adverse events.
High-dose PPI and aspirin chemoprevention therapy, especially in combination, significantly and safely improved outcomes in patients with Barrett's oesophagus.
Cancer Research UK, AstraZeneca, Wellcome Trust, and Health Technology Assessment.
Since 2008, a plethora of research studies has compared the efficacy of water-assisted (aided) colonoscopy (WAC) and underwater resection (UWR) of colorectal lesions with standard colonoscopy. We ...reviewed and graded the research evidence with potential clinical application. We conducted a modified Delphi consensus among experienced colonoscopists on definitions and practice of water immersion (WI), water exchange (WE), and UWR.
Major databases were searched to obtain research reports that could potentially shape clinical practice related to WAC and UWR. Pertinent references were graded (Grading of Recommendations, Assessment, Development and Evaluation). Extracted data supporting evidence-based statements were tabulated and provided to respondents. We received responses from 55 (85% surveyed) experienced colonoscopists (37 experts and 18 nonexperts in WAC) from 16 countries in 3 rounds. Voting was conducted anonymously in the second and third round, with ≥80% agreement defined as consensus. We aimed to obtain consensus in all statements.
In the first and the second modified Delphi rounds, 20 proposed statements were decreased to 14 and then 11 statements. After the third round, the combined responses from all respondents depicted the consensus in 11 statements (S): definitions of WI (S1) and WE (S2), procedural features (S3-S5), impact on bowel cleanliness (S6), adenoma detection (S7), pain score (S8), and UWR (S9-S11).
The most important consensus statements are that WI and WE are not the same in implementation and outcomes. Because studies that could potentially shape clinical practice of WAC and UWR were chosen for review, this modified Delphi consensus supports recommendations for the use of WAC in clinical practice.
Summary
Background
The British Society of Gastroenterology has recommended the Edinburgh Dysphagia Score (EDS) to risk‐stratify dysphagia referrals during the endoscopy COVID recovery phase.
Aims
...External validation of the diagnostic accuracy of EDS and exploration of potential changes to improve its diagnostic performance.
Methods
A prospective multicentre study of consecutive patients referred with dysphagia on an urgent suspected upper gastrointestinal (UGI) cancer pathway between May 2020 and February 2021. The sensitivity and negative predictive value (NPV) of EDS were calculated. Variables associated with UGI cancer were identified by forward stepwise logistic regression and a modified Cancer Dysphagia Score (CDS) developed.
Results
1301 patients were included from 19 endoscopy providers; 43% male; median age 62 (IQR 51–73) years. 91 (7%) UGI cancers were diagnosed, including 80 oesophageal, 10 gastric and one duodenal cancer. An EDS ≥3.5 had a sensitivity of 96.7 (95% CI 90.7–99.3)% and an NPV of 99.3 (97.8–99.8)%. Age, male sex, progressive dysphagia and unintentional weight loss >3 kg were positively associated and acid reflux and localisation to the neck were negatively associated with UGI cancer. Dysphagia duration <6 months utilised in EDS was replaced with progressive dysphagia in CDS. CDS ≥5.5 had a sensitivity of 97.8 (92.3–99.7)% and NPV of 99.5 (98.1–99.9)%. Area under receiver operating curve was 0.83 for CDS, compared to 0.81 for EDS.
Conclusions
In a national cohort, the EDS has high sensitivity and NPV as a triage tool for UGI cancer. The CDS offers even higher diagnostic accuracy. The EDS or CDS should be incorporated into the urgent suspected UGI cancer pathway.
In a national cohort of patients referred with dysphagia, an updated Cancer Dysphagia Score offered higher diagnostic accuracy as a triage tool for upper gastrointestinal (UGI) cancer than Edinburgh Dysphagia Score, especially for younger patients. These scoring systems should be validated in primary care and incorporated into the urgent UGI cancer pathway.
The significant reduction in non-value-added time for patients being assessed remotely should result in patients being even more amenable to a trainee or trainer ‘sitting in’ on their consultation.1 ...Return of specialist teams The essential redeployment of healthcare staff to COVID-19-related duties has meant that gastroenterology services have been adversely affected.6 Ninety-two per cent of services have had their specialist nurses redeployed elsewhere. A study from Wolverhampton showed that enhanced senior triage can result in a reduction in costs as well as clinical benefits such as: 21% could be discharged back to primary care following initial investigations and 32% could be managed without a consultation.9 Redesigning services is a team effort and requires the participation of the gastroenterology team including specialist nurses, physician associates, primary care, allied health professionals, administrators and management. Audit Specific examples of outcomes to audit include: patient feedback/satisfaction, percentage requirement for face to face consultations, use of the Edinburgh Dysphagia Audit Tool10 for a 2-week wait/red flag upper gastrointestinal endoscopy triage; audit of inflammatory bowel disease (IBD) helplines renumber of patient calls and outpatient (OP) clinics or A+E attendance avoided; Departmental review of redesigned pathways at 3 and 6 months using audit data to further improve local patient pathways using plan–do–study–act techniques. ...COVID-19 provides challenges but also a unique and powerful catalyst to reboot and redesign sustainable services to benefit patients and also improve the work-life balance of healthcare professionals.
A protocol-driven, systematic pathway was developed to allow rapid and coordinated investigation of patients with iron-deficiency anemia (IDA) in a nurse-delivered outpatient setting. The study ...objective was to assess the safety and efficacy of the pathway by 5-year outcome data for the exclusion of gastrointestinal (GI) malignancy. This is a 5-year follow-up study of 122 patients entered onto the pathway with negative initial upper and lower GI investigations. The study was conducted at Hereford County Hospital NHS Trust (a district general hospital serving 220,00 people). Clinical outcomes of patients at 5 years and service efficiency at detecting relevant pathology were observed. A total of 272 patients were investigated through the pathway, and in 150 patients a GI cause for IDA was found. We established the outcome in 97% of the 122 patients with normal GI investigation at 5 years after their initial investigation. Of the 118 patients followed up, 92 patients were alive and well and 26 had died or developed malignancy. With the exception of diabetes (odds ratio 0.24; 95% confidence interval 0.1, 0.8; p = .02), no features were found to be a significant risk factor for poor prognosis, including age, gender, hemoglobin level, anemia at 3 months, or other comorbidities. Three patients developed colonic malignancy; two patients had diverticular disease at barium enema and presented 4 years later with colorectal cancer. One patient declined lower GI investigation and presented with metastatic colon cancer on computed tomography scan at 1 year. No other GI cancers were diagnosed. Our nurse-delivered, protocol-driven pathway is a highly effective and safe system for the exclusion of GI cancer within 5 years of follow-up.
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